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Frequency Gradient Within Coronary Sinus Predicts the Long-Term Outcome of Persistent Atrial Fibrillation Catheter
Xiaomeng Yin1, Ziming Zhao1, Lianjun Gao1
1First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
Insights
Coronary sinus (CS) rapid activities can maintain atrial fibrillation (AF). A distal to proximal CS frequency ratio below 67% predicts better outcomes for AF ablation patients.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Ablation
Background:
- The coronary sinus (CS) plays a role in atrial fibrillation (AF) maintenance through unstable reentry.
- Atrial ablation targeting the CS may terminate AF.
- This study investigates AF activity in the CS and its prediction of ablation outcomes.
Purpose of the Study:
- To evaluate if AF activities in the coronary sinus (CS) contribute to AF maintenance.
- To determine if CS activity predicts the clinical outcome of AF ablation.
- To identify patient subsets who may benefit from CS ablation.
Main Methods:
- 122 patients undergoing first-time radiofrequency ablation for persistent AF were studied.
- Bipolar electrograms from the left atrium were recorded using a Lasso mapping catheter.
- Pulmonary vein isolation was performed, followed by stepwise ablation in non-responders.
Main Results:
- Pulmonary vein isolation alone terminated AF in 9.8% of patients.
- Stepwise ablation achieved termination in an additional 18% of patients.
- A lower distal CS to proximal CS frequency ratio (CSd/CSp ratio < 67%) was associated with significantly better ablation outcomes.
Conclusions:
- Rapid activities in the proximal CS musculature may sustain persistent AF post-pulmonary vein isolation.
- The CSd/CSp frequency ratio, with a cutoff of 67%, can stratify patients likely to benefit from additional CS ablation.
- This ratio serves as a predictor for improved success rates in AF ablation.
Background:
The coronary sinus (CS), as a junction of the atria, contributes to atrial fibrillation (AF) by developing unstable reentry, and isolating the atria by ablation at the CS could terminate AF. The present study evaluated whether AF activities at the CS in a subset of patients contributed to AF maintenance and predicted clinical outcome of ablation.
Methods And Results:
We studied 122 consecutive patients who had a first-time radiofrequency ablation for persistent AF. Bipolar electrograms were obtained from multiple regions of the left atrium by a Lasso mapping catheter before ablation. Pulmonary vein isolation terminated AF in 12 patients (9.8%). Sequential stepwise ablation was conducted in pulmonary vein isolation nontermination patients and succeeded in 22 patients (18%). In the stepwise termination group, AF frequency in the proximal CS (CSp) was significantly higher (10.2±2.1 Hz versus 8.3±1.8 Hz, P<0.001), and the ratio of distal CS (CSd) to proximal CS (CSd/CSp ratio, 56.6%±10.11% versus 70.7%±9.8%, P<0.001) was significantly lower than that in the nontermination group. The stepwise logistic regression analysis indicated that the CSd/CSp ratio was an independent predictor with an odds ratio of 1.131 (95%CI 1.053-1.214; P=0.001). With a cutoff of 67%, the patients with lower CSd/CSp ratios had significantly better index and long-term outcomes than those with higher ratios during a follow-up of 46±18 months.
Conclusions:
Rapid repetitive activities in the musculature of the proximal CS may contribute to maintenance of AF after pulmonary vein isolation alone in persistent AF. A cutoff at 67%, of the CSd/CSp frequency ratio might be an indicator to stratify the subset of patients who might benefit from CS ablation.
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